Donna Cohen Ross, Outreach Director, Center on Budget and Policy Priorities.
Editor's Note: Donna Cohen Ross has been tracking state eligibility rules, enrollment and renewal procedures and cost-sharing practices in Medicaid and CHIP for more than a decade. Her much anticipated annual survey was released last week by the Kaiser Commission on Medicaid and the Uninsured and the Center on Budget and Policy Priorities. We asked Donna to give us the highlights in a guest blog entry.
What's most striking in this year's 50-state survey on Medicaid and CHIP is that despite the deep, deep "downs" of the economy, many states were reporting impressive "ups" for children's health coverage. In fact, a substantial number of states did more than survive in the depressed economic environment -- they reached new heights (which is consistent with CCF's Weathering the Storm findings).
How did they manage to do that? Flip the pages of the calendar back to February 2009 for the answer. That month, CHIPRA was signed into law, providing sufficient resources to cover, by 2013, an additional 4.1 million children under Medicaid and CHIP who would otherwise remain uninsured. In addition, an Executive Order rescinded the August 17th directive, removing the constraints that had hampered states' ability to expand coverage to children in more moderate-income families. Later that same month, the American Recovery and Reinvestment Act (ARRA) was enacted, infusing states with fiscal relief by bumping up federal matching funds for Medicaid and prohibiting states from cutting Medicaid eligibility or putting up procedural barriers to enrollment. (These eligibility and enrollment protections did not apply to CHIP, leaving that program vulnerable to cuts.)
It's now clear these measures were vital in helping health coverage programs rise to the challenge of providing coverage for low-income families as they faced what have been the toughest times many have ever experienced. Let's take a look at the specific ups and downs of 2009:
The Ups:
- In 2009, more than half the states (26) took at least one step to advance health coverage for low-income children, parents and pregnant women, with children being the biggest beneficiaries. Nine states expanded income eligibility for children so that the median income eligibility for children rose to 235 percent of the federal poverty line from 200 percent, and now 24 states (including DC) cover children in families at 250 percent of the federal poverty line or higher.
- Nine states took steps to simplify enrollment and renewal procedures -- notably, five adopted 12-month continuous eligibility, which guarantees eligible children a full year of coverage, an important step in fostering retention.
- There is no doubt that the tools and incentives states got from CHIPRA helped push them forward. More than one-third of the states (18) have submitted state plan amendments to cover immigrant children and pregnant women who have been legally residing in the U.S. for less than five years; and more than half the states (27) said they plan to conduct data matches with SSA to meet the citizenship documentation requirement, rather than requiring families to come up with documents like passports, original birth certificates and picture IDs. State officials also said they were interested in trying out the new Express Lane Eligibility option and a handful said they will provide language and interpreter services (and get enhanced federal administrative match) for enrollment activities.
The Downs:
- To be sure, there also were some "downs," with 15 states restricting access for children. Increasing CHIP premiums was the action states took most frequently in response to economic pressures. In some states the premium jumps were big, but even after these recent increases, overall, CHIP premiums remain modest with the median charge for two children in a family with income at 200 percent of the federal poverty line is $480 per year ($40 per month), just 1.3 percent of annual income. Another "down" is that two states -- California and Tennessee -- froze CHIP enrollment for at least part of the year. California reopened enrollment, but Tennessee remains closed. Of greatest concern is that these access-restricting measures mean that eligible children can't enroll and will remain uninsured. So, a sick child can't see a doctor or get the medicine she needs and her family may face compelling financial choices -- pay the rent or pay for a prescription -- even though the child qualifies for coverage.
Where do we end up as 2009 comes to a close? The stabilizing effects of ARRA gave states the support they needed to safeguard coverage for low-income families and move forward. But, the federal fiscal relief and enrollment protections are scheduled to expire at the end of 2010. If that happens, states will no longer have the emergency resources that have been instrumental in keeping their programs intact. While there are indications that the economy may be beginning to recover, the recession continues to take a toll on families and communities across the nation. If fiscal relief is not replenished and Medicaid is not protected as under ARRA, many states may buckle under the pressure they are facing to make substantial cuts in programs like Medicaid and CHIP. Will the "ups" of 2009 turn upside down in 2010?
The views expressed by Guest Bloggers do not necessarily reflect the views of the Center for Children and Families.
Here in Alabama, our first-in-the-nation CHIP is one of the few policy successes we can crow about. In the midst of a recession, our Legislature voted last spring to increase eligibility from 200 percent to 300 percent FPL. When CHIPRA came down, our strong coalition of state agencies and advocates pounced on the opportunity to strengthen the program even further. This fall we've introduced an Express Lane system that's designed to grow in both functional scope and program partners over the next few years. These advances in children's coverage only heighten the stark reality for Alabama parents -- our MLIF income limits come in at around 12 percent FPL! In budget hearings this week, our Medicaid commissioner called proposed Medicaid expansions in the health care reform bills a disaster for Alabama. While we disagree with her on the expansion issue in general, we agree that states need more help with both coverage and administrative costs.
This year Texas had no program cuts but no enhancements. Texas advocates fought, but lost, a fight for 12 months coverage for Medicaid and a buy-in program for families above 200% FPL. Those two things alone would move Texas out of last place - we have the highest rate of uninsured children in the nation!
Given what Donna reports in this blog, we will be watching what happens over the next year very closely. We cannot afford to have ANY program cuts! We are glad for the progress other states made in 2009 and will continue to work for progress here in Texas.
Blogs like this keep advocates informed about trends and policies that are working to keep children and families covered! That is information we all need and want to hear.
While funding for Ohio's CHIP expansion to 300% FPL is tied up in the courts, advocates are putting a full court press on to get more of our state's 77,000 uninsured eligible kids enrolled in our Medicaid/CHIP program through further simplification and a strong focus on retention. Knowing what other states are doing and the trends in enrollment and renewal policies and practices helps us develop smarter recommendations and strategies. We rely on the annual Kaiser report that Donna Cohen Ross and her colleagues produce for updated information and good ideas. Congrats to so many states who continue to make progress in covering more kids.
Nine states got some holiday cheer from CMS today to the tune of more than $70 million in CHIPRA performance bonuses! I'm sure the CCF bloggers will be illuminating us all on that soon enough! In the meantime, let's remember that to qualify for bonuses, states have to show that they've adopted procedures that simplify enrollment and renewal (the program elements our survey has been tracking for a decade!) These are important steps for states to take if they want to reduce the number of uninsured children, even if they are not in line for a performance bonus. Congrats to the states that earned their bonuses. (Jim, your state -AL-came out on top!) Hopefully, states will use the money to further improve enrollment systems (for parents too!)and cover more of their (as yet) uninsured people.
Here in Oregon, we're expanding coverage to 80,000 more uninsured children and drawing down more of the federal matching funds we've left on the table in the past. This means our health care expansion is good for kids and good for our state economy. In addition, we're please to be one of the 9 states recently awarded performance bonuses.